In 2000 21% of nursing facilities nationally were cited for general quality of care deficiencies, 13% for poor resident assessment, and 17% for failure to provide a comprehensive care plan. Nurse staffing has an important influence on the delivery of nursing home care. Nonetheless, nurse-staffing levels varied over the past years, particularly under the Balanced Budget Act. It is unclear how those staff changes may have affected nursing homes' quality of care. The purposes of this study are to 1) assess the validity and reliability of the construct of nursing care quality, using administrative and assessment data; 2) examine differences or variations in nursing care quality with an institutional framework; 3) identify the effect of nurse staffing and nursing care adequacy on nursing care quality, controlling the effects of institutional (contextual and market) factors; 4) evaluate the impact of the Balanced Budget Act on nursing home practice and quality; 5) perform benchmarking and profile analysis of high-performance nursing homes, 6) perform multilevel analysis of the effects of contextual or institutional factors on nurse staffing, nursing care adequacy and nursing care quality of nursing homes;7) determine the concurrent validity of nursing care quality indicators, using nursing homes' administrative data (OSCAR) and Minimum Data Set (MDS) resident assessment data. The study will use an administrative dataset--the Online Survey, Certification, and Reporting (OSCAR)_compiled from a panel of 14,000 facilities in 1997-2004. These panel data will be merged with the Area Resource File to capture the contextual and market characteristics associated with the distribution of nursing home facilities. Multivariate statistical modeling techniques will be used to analyze the eight waves of OSCAR data and four years of MDS data to be available: confirmatory factor analysis of nursing care quality in nursing homes (Aim 1), covariance structure modeling of institutional determinants of nursing care quality (Aim 2), multilevel analysis of the mediating effect of nurse staffing on nursing care quality (Aim 3), growth curve modeling of changes in nurse staffing and in quality (Aim 4), benchmarking analysis of high-quality facilities (Aim 5), multilevel covariance analysis and growth curve modeling of contextual effects on the structure-process-outcome of nursing care quality (Aim 6), and concurrent validation with OSCAR and MDS quality indicators by confirmatory factor analysis (Aim7). Our proposal focuses on important predictors of the trajectories of nursing facilities' nurse staffing and quality. Our findings will demonstrate the importance of nurse staffing and drive the development of operational strategies to improve the structural and process aspects of nursing home quality.